How should you bill and code for patients with diabetes?

More than 14 million Americans have Type 2 diabetes, making treating Medicare patients who have diabetes a staple of most internal medicine practices.

This is the first of a two-part series on how internists should bill and code for those services. The information is based on Medicare regulations, but likely has broader applications because most health plans base their own billing and coding requirements on Medicare rules. Check with your local health plans to see if they follow Medicare requirements or have different ones of their own.

When treating patients with diabetes, you can bill for services including evaluation and management (E/M) services based on history, exam and medical decision-making, as well as for counseling and lab tests. (Billing and coding for counseling and for preventive E/M services will be covered in my column in the November ACP Observer.) Proper billing and coding will ensure that you get paid appropriately for your time and services—and help you comply with evidence-based guidelines that payers commonly track.

A: Physicians typically determine their level of E/M service according to the type of history, exam and level of medical decision-making they used.

Because many medically necessary E/M services furnished to diabetics involve a hands-on exam, you first need to decide whether the exam you furnished was problem focused; expanded problem focused; detailed; or comprehensive. You must then determine the text of history and medical decision-making you performed to arrive at your level of service.

You can, however, select the E/M service level based on encounter time if counseling accounts for more than 50% of the total encounter time. That is defined as face-to-face time in the office or other outpatient setting or floor/unit time in the inpatient setting. (More information on billing for medically necessary counseling will appear in the November 2004 ACP Observer.)

You also need to take into account the fact that Medicare maintains two different sets of documentation guidelines—one established in 1995 and the other in 1997. Each of those two sets specifies the kind of documentation expected for each E/M service level for history, exam and decision-making.

The major difference between the two guidelines is in the exam section. The exam section of Medicare's 1995 guidelines is more straightforward, providing a general description of a multisystem exam.

The 1997 guidelines, on the other hand, give a more comprehensive description of a general multisystem exam and define the components of 10 single organ system exams. Medicare added the single multisystem exam guidelines in 1997 to allow specialists, who often focus an exam on a single organ system, to reach the highest level of service. When selecting a level of E/M service to code and bill, physicians have the option of using either the 1995 or 1997 guidelines.

The complete 1995 Medicare documentation guidelines are online, while the complete 1997 Medicare documentation guidelines are also online. Here is a brief summary of the exam section of the 1995 and 1997 guidelines:

According to the 1995 general multisystem exam documentation guidelines, the documentation requirements that pertain to the four types of exam are defined as follows:

Problem focused: a limited exam of the affected body area or organ system.

Expanded problem focused: a limited exam of the affected body area or organ system and other symptomatic or related organ system(s)

Detailed: an extended exam of the affected body area(s) and other symptomatic or related organ system(s)

Comprehensive: a general multi-system exam or complete exam of a single organ system.

For purposes of exam, the following body areas are recognized:

Head, including the face

Neck

Chest, including breasts and axillae

Abdomen

Genitalia, groin, buttocks

Back, including spine

Each extremity

For purposes of the exam, the following organ systems are recognized:

Constitutional (which includes vital signs, general appearance)

Eyes

Ears, nose, mouth and throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Skin

Neurologic

Psychiatric

Hematologic/lymphatic/immunologic

The extent of exam performed and documented depends upon clinical judgment and the nature of the presenting problem(s). Exams range from a limited exam of single body areas to general multisystem or complete single organ system exam.

The 1997 single organ system exam documentation guidelines, on the other hand, state that any three of the following seven vital signs are the equivalent to the exam of one bullet under an organ system in a general multisystem exam:

Sitting or standing blood pressure

Supine blood pressure

Pulse rate and regularity

Respiration

Temperature

Height

Weight

For a general multisystem exam, the following content and documentation requirements should be met to qualify for a given level of multisystem exam:

Problem focused exam: should include performance and documentation of one to five elements identified by a bullet (o) in one or more organ system(s) or body area(s).

Expanded problem focused exam: should include performance and documentation of at least six elements identified by a bullet (o) in one or more organ system(s) or body area(s).

Detailed exam: should include at least six organ systems or body areas. For each system/area selected, performance and documentation of at least two elements identified by a bullet (o) is expected. Alternatively, a detailed exam may include performance and documentation of at least twelve elements identified by a bullet (o) in two or more organ systems or body areas.

Comprehensive exam: should include at least nine organ systems or body areas. For each system/area selected, all elements of the exam identified by a bullet (o) should be performed, unless specific directions limit the content of the exam. For each area/system, documentation of at least two elements identified by a bullet is expected.

These types of exam have been defined for general multisystem and the following single organ systems:

Cardiovascular

Ears, nose, mouth and throat

Eyes

Genitourinary (female)

Genitourinary (Male)

Hematologic/lymphatic/immunologic

Musculoskeletal

Neurological

Psychiatric

Respiratory

Skin

An ACP Practice Management Center (PMC) tool for selecting and documenting E/M levels of service is available online.

Q: How should I code and bill for elements that are part of an E/M service that Medicare considers medically necessary?

A: When treating diabetic patients, internists typically bill the following E/M service elements:

Blood pressure reading/weight measurement. The billing code would depend on the appropriate E/M service code.

In selecting a level of service with corresponding documentation requirements, you would likely provide a blood pressure reading/weight measurement to a diabetic patient in the context of a general multisystem exam. The 1995 Medicare documentation guidelines are simpler than the 1997 guidelines for a general multisystem exam.

Under the 1995 guidelines, blood pressure reading and weight measurement are considered part of the "Constitutional" organ system. You would determine the type of exam by counting the number of body areas and organ systems examined, including the "Constitutional" organ system exam.

Unlike the 1995 guidelines, the 1997 documentation guidelines do not include a "Constitutional" body area as a separate organ system exam. The 1997 guidelines do, however, describe the vital signs considered to be "Constitutional" in the context of a general multisystem exam.

If a blood pressure reading/weight measurement was the only service you furnished during an encounter, you should bill it as a low level office visit, using CPT code 99211-99212.

Eye exam. Your billing code would depend on the appropriate E/M service code.

When selecting a level of service, your evaluation of a diabetic patient's eyes is likely to be in the context of a general multisystem exam. In you are using the 1995 documentation guidelines, you should determine the type of exam by counting the number of body areas and organ systems examined, including the "Eyes" organ system. Exams that focus exclusively on the eyes are typically furnished by ophthalmologists and billed using CPT 92002 and 99204; and 92012 and 92014.

However, if you perform an exam focused exclusively on a diabetic beneficiary's eyes, you may want to consult the more expansive 1997 documentation guidelines. They provide specific documentation guidance for an "Eyes" single organ system exam.

Foot exam. Once again, your billing code would depend on the appropriate E/M service code.

Your exam of a diabetic beneficiary's feet is likely to be in the context of a general multisystem exam. Determine the type of exam by counting the number of body areas and organ systems examined, including the "Musculoskeletal" and/or "Skin" organ system that would account for the foot exam.

However, as with the eye exam, if your exam focuses exclusively on a diabetic beneficiary's feet, you may want to consult the broader 1997 documentation guidelines and specific documentation guidance for a "Musculoskeletal" and "Skin" single organ system exam.

Counseling. When treating diabetic patients, you can bill for physician counseling for such services as smoking cessation and weight counseling, as well as for medically necessary counseling provided in your office by a nonphysician health professional and for nonphysician medical nutrition therapy. Billing and coding for those services will be covered in my next column.

Because it pays for medically necessary laboratory tests, Medicare will probably pay for lab tests related to diabetic care if those tests are supported by a diagnosis code(s) indicating diabetes and/or a pertinent symptom.

Medicare typically maintains national or local coverage decision policies to identify the diagnosis codes that justify payment for each lab test. If you order or perform a test for a non-covered diagnosis, Medicare will considered it done for screening purposes. You can submit support documentation to try to convince Medicare to pay for it as medically necessary under specific circumstances.

If you think Medicare may deny coverage of a test, ask your Medicare patient to sign an advance beneficiary notification (ABN) form, acknowledging payment responsibility. You can then charge the patient your usual charge for that test. For more information on ABN forms, see "Think Medicare won't cover it? Use this new form" in the March 2003 ACP Observer.

Medicare typically covers he following tests for patients with Type 2 diabetes:

The Centers for Medicare and Medicaid Services (CMS) maintains a national coverage policy pertaining to hemoglobin Alc and lipid testing, which includes both a lipid panel and a Lipoprotein, direct measurement; low density cholesterol (LDL) cholesterol test. These national policies are online under "Glycated Hemoglobin/Glycated Protein" and "Lipid Testing," respectively.

In addition, some Medicare carriers may have a local policy related to a hemoglobin Alc test, a lipid panel, a LDL cholesterol test and albumin tests. You can search the Medicare coverage database through the CMS' Web site to see if your local carrier maintains any pertinent local policies.

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